The Keele STarT Back approach is effective for stratifying patients with low back pain in primary care, but a similar approach has not been tested with a broader range of patients with musculoskeletal (MSK) pain. We report a feasibility and pilot trial examining the feasibility of a future main trial of a primary care based, risk-stratification (STarT MSK) approach for patients with back, neck, knee, shoulder or multi-site pain. A pragmatic, two-parallel arm, cluster randomised controlled trial (RCT) in 8 GP practices (4 stratified care involving use of the Keele STarT MSK tool and matched treatment options: 4 usual care). Following screening, adults with one of the five most common MSK pain presentations were invited to take part in data collection over 6 months. Feasibility outcomes included exploration of selection bias, recruitment and follow-up rates, clinician engagement with using the Keele STarT MSK tool and matching patients to treatments.Background and aims
Methods
Low back pain (LBP) is a major health challenge globally. Research has identified common trajectories of pain over time. We aimed to investigate whether trajectories described in one primary care cohort can be confirmed in another, and to determine the prognostic value of factors collected 5 years prior to the identification of the trajectory. The study was carried out on 281 patients who had consulted primary care for LBP, at that point completed a baseline questionnaire, and then returned a questionnaire at 5-years follow-up plus at least 3 (of 6) subsequent monthly questionnaires. Baseline factors were measured using validated tools. Pain intensity scores from the 5-year follow-up and monthly questionnaires were used to cluster participants into 4 previously derived pain trajectories (no or occasional mild, persistent mild, fluctuating, persistent severe), using latent class analysis. Posterior probabilities of belonging to each cluster were estimated for each participant. The posterior probabilities for the assigned clusters were very high (>0.90) for each cluster except for the smallest ‘fluctuating’ cluster (0.74). Lower social class (OR 2.9; 95% CI 1.2, 7.0), higher pain intensity (1.6 per unit; 1.2, 2.2), and pain duration greater than 3 years (2.7; 1.0, 7.3), were significantly associated with a more severe trajectory 5-years later, as were higher physical disability, emotional impact of pain, and perception pain will last a long time.Background and objectives
Methods and results
Anterior only procedure for stable thoraco-lumbar burst fractures is controversial. Prospective collection of clinical and radiological data in stable burst fractures with neurological deficit undergoing anterior only decompression and stabilisation with 2-year follow-up. 14 consecutive patients (8 females, 6 males) with two-column thoracolumbar burst fracture and neurological deficit underwent anterior corpectomy/hemi-corpectomy and instrumentation, from February 2007 to February 2009. Radiological data included classification of fracture (AO classification), kyphus angle and degree of canal compromise. Post-operative CT scans done to assess radiological improvement. Clinical data included neurological deficit at presentation, improvement or changes in neurology, length of surgery, estimated blood loss, post-operative complications and length of stay. Commonest mechanism was fall from height. 10 patients had incomplete burst fractures amenable to hemi-corpectomy. 8 of our patients were ASIA D, 4 were ASIA C or lower. They all improved by at least one grade. 2 patients had identical ASIA grade pre and post operatively. Pre-operative spinal canal compromise averaged 52.6% and vertebral body height loss averaged 48.9%. The mean kyphotic angles improved from 19.6° to 7.9 °. There were two cases with minor injury to the diaphragm, one developing a pneumothorax. Mean length of surgery and hospital stay were 4hours and 21minutes and 11.8 days respectively. The fractures in which the top part is burst and causing canal compromise, could be dealt with by top hemi-corpectomy requiring smaller approach. One stage anterior – only stabilization can yield successful clinical results.
Magnetic Resonance Imaging (MRI) is the cornerstone investigation for cervical disc disease (CDD). However, MRI changes suggestive of CDD are found in people above forty, even in asymptomatic healthy individuals [1]. Mere presence of MRI changes of CDD does not exclude the presence of concomitant extra-foraminal pathology. No study design. We present here a series of three cases where use of ‘high resolution ultrasound’ has allowed accurate diagnosis of concomitant extra-foraminal pathology in patients with MRI-proven CDD. The three cases were acute neuropraxia of aberrant C5 nerve root, anterior interossous nerve compression due to pseudo-aneurysm of brachial artery and ‘acute brachial neuritis’ respectively. No outcome measure. Use of diagnostic high resolution ultrasound revealed accurate diagnosis of concomitant extra-foraminal pathology in all three cases. The cases with acute neuropraxia and acute brachial neuritis recovered with conservative treatment. Pseudo-aneurysm was treated successfully with surgery. High resolution ultrasound of the brachial plexus and peripheral nerves may be useful in following scenarios to identify an extra-foraminal pathology: (1) when symptoms and signs are out of proportion to the MRI findings of CDD; (2) when there is obvious discordance between MRI and nerve conduction findings; (3) where an entrapment neuropathy is suspected but the site of nerve lesion cannot be located.
